Int J Emerg Med (2009) 2:135–139 DOI 10.1007/s12245-009-0122-y

STATE OF INTERNATIONAL EM

Emergency medicine in , UAE

Robert Partridge & Michael Abbo & Alamjit Virk

Received: 2 February 2009 /Accepted: 6 July 2009 /Published online: 18 August 2009 # Springer-Verlag London Ltd 2009

Abstract Dubai has rapidly risen to prominence in the Introduction Persian Gulf region as a center of global commerce and tourism and as a cultural crossroad between East and West. Dubai is the largest of the seven emirates comprising the The health-care infrastructure has undergone rapid devel- (UAE) (Fig. 1). Arabic is the official opment. Collaborations with academic medical centers now language of Dubai, but English is widely spoken in the exist to advance clinical care, teaching and research. medical and business settings, and medical training and Emergency medicine has also advanced and is undergoing practice largely follow a Western model. The development dynamic change. Dubai may soon emerge as a regional of emergency medicine (EM) is variable across the UAE. leader in emergency medicine training and practice. Practice in Dubai is advancing rapidly, and the emirate is poised to become a regional leader in EM care. Keywords Dubai . Emergency department . International . This report describes the structure of the health-care system Trauma . Emergency medical services in Dubai, with particular emphasis on EM. It examines medical education, the organization of health-care services, emergency department (ED) structure, and the challenges The views expressed in this paper are those of the author(s) and not ’ those of the editors, editorial board or publisher. facing EM. Information from Dubai s Department of Health and Medical Services (DOHMS), the Ministry of Health R. Partridge (MOH) for the UAE, visits and physicians practicing Department of Emergency Medicine, Warren Alpert School of Medicine at Brown University, emergency medicine in Dubai provided material for this Providence, RI, USA report.

R. Partridge Division of International Emergency Medicine, Warren Alpert School of Medicine at Brown University, Background Providence, RI, USA Dubai’s rapid economic expansion began several decades M. Abbo ago with the discovery and export of oil, and has since been Department of Emergency Medicine, Rashid Hospital and , further fueled by the emirate’s status as a tax-free port. The Dubai, UAE foundations of its economy are now trade, manufacturing : and financial services; only 6% of Dubai’s gross domestic R. Partridge A. Virk product comes from oil [1]. Tourism has mushroomed, and Department of Emergency Medicine, Emerson Hospital, Concord, MA, USA 10 million visitors are expected annually by 2010 [2]. Emiratis now enjoy one of the highest per capita incomes R. Partridge (*) worldwide [3]. A significant result of Dubai’s economic Department of Emergency Medicine, Rhode Island Hospital, growth is an investment in medicine and improvement in 593 Eddy Street, Claverick 2, Providence, RI 02903, USA the standard of medical care. As the health-care infrastruc- e-mail: [email protected] ture has expanded—including the construction of clinics, 136 Int J Emerg Med (2009) 2:135–139

Fig. 1 United Arab Emirates map, showing the location of the Emirate of Dubai. Map from Central Intelligence Agency World Factbook (https:// www.cia.gov/library/publications/the-world-factbook/geos/ae.html) , specialized care centers and postgraduate teaching A new multidisciplinary provider of inpatient and facilities—representation of EM and other medical specialties outpatient services, Dubai Health Care City (DHCC), is has also increased [4]. expected to be complete in 2011. DHCC is designed as a The population of Dubai is estimated to be 1.65 million regional center of excellence in clinical care, education and people, of which 76% are male [5]. Of the total population, research. A private enterprise, DHCC will function without only about 17% are UAE nationals; most of the remainder oversight from the DOHMS or MOH. Postgraduate medical are guest workers from India, Pakistan, Bangladesh and the education and research programs are affiliated with Harvard Philippines [6]. Approximately 2% of the expatriate University, and dental education and research programs are population originates from Western countries [6]. The affiliated with Boston University [11]. When DHCC is median age is 32 years for males and 24.5 years for complete, it will add 18 specialty hospitals, including a 400- females [7]. Only 0.6% of the population is over the age of bed academic medical center and 2,125 new inpatient beds, 65 [7]. Adult literacy is reported to be 77.9% [3]. The infant to Dubai’s medical infrastructure [12]. The academic medical mortality rate was estimated at 8.0 deaths per 1,000 live center will include a 36-bed ED, capable of accommodating births in 2007 [8]. 50,000 patient visits annually. A hospital-based EMS service Health care in Dubai is provided primarily by expatriate is planned at this facility and will provide service coopera- physicians from the Middle East, India, Pakistan, Canada tively with the DOHMS ambulance services. and the UK, in addition to some Emirati physicians; nursing staff in hospitals and clinics originate largely from India and the Philippines. Licensure is granted by the Dubai Graduate and postgraduate medical education Health Authority (a division of the DOHMS) after demonstration of equivalency training and licensure from Graduate and postgraduate medical education in the UAE the practitioner’s home country [9]. follows the European model. After completion of the US EM in Dubai is well developed, with an advanced equivalent of high school, students attend medical school physical infrastructure, diagnostic equipment and therapies for 5 years. The only medical school in Dubai is the Dubai available in most hospitals. Prehospital care is widely Medical College for Girls, a private institution that accepts available. Two large government-run tertiary care centers, 100 students per class [13]. The UAE has three other and Rashid Hospital, provide all medical medical schools, the largest of which is the government- and surgical subspecialties. Rashid is also the site of the funded Emirates University Medical School in Al Ain [14– first postgraduate EM training program in the UAE [10]. 16]. Postgraduate training is available in , Medical and surgical postgraduate training programs exist surgery, obstetrics and gynecology, pediatrics, family in both the government hospital system and the private medicine, community medicine, psychiatry and emergency system, and more are planned in the near future [10]. medicine. Int J Emerg Med (2009) 2:135–139 137

The training structure follows the British system, with Emergency medical services trainees progressing through senior house officer, registrar, senior registrar, specialist registrar and finally consultant Emergency medical services (EMS) are available throughout (the equivalent of attending in the US). Training in internal the Emirates. Dubai has a centralized EMS system that medicine and general surgery is completed over 5 years. dispatches 120–150 ambulances per day [18, 19]. Approxi- Dubai Hospital and Rashid Hospital are the main teaching mately 50–70 inter-hospital ambulance transfers occur daily. hospitals. Faculty members monitor clinical performance The Center of Ambulance Services (COAS) was created in and have didactic programs similar to those available at 2006, merging the services of the Dubai police and the teaching hospitals in the United States. British qualification DOHMS, the latter of which had previously offered only examinations are offered to candidates who have completed inter-facility transportation. Call reception and ambulance training [17]. dispatch are provided by the Dubai police and COAS Dubai has one EM training program for physicians. The personnel assigned to police communications. There is a inaugural class, consisting of ten residents representing six single emergency response activation telephone number, countries, started their training at Rashid Hospital in July 999. Ambulances are based near hospitals and in several 2008. Among the prerequisites for admission are the current and emerging population centers. COAS operates completion of a transitional year, an entrance interview approximately 40 ambulances daily, including 2 mobile and a passing grade in the intern exam administered by the intensive care units and 6–7 fast-responder units and motor- DOHMS. A new residency program in EM is anticipated at cycles. Four paramedics (a term used to describe all levels of DHCC when it opens in 2011. Board examination and prehospital providers) are assigned to police helicopter duty. certification for qualified candidates are expected through Paramedics are also assigned to the communications center, the British Board of Emergency Medicine for graduates of clinics, the airport and to support unit arrival at Rashid and the government program. Dubai is in the process of Dubai Hospitals. Ambulances are normally staffed with two developing new accreditation standards, which will also paramedics and a driver. The primary work week averages apply to EM. The largest EM conference in Dubai is the 40+ h, completed in 8-h shifts. Most prehospital personnel annual Dubai International Emergency and Catastrophe are expatriate workers. Management Conference; in addition, the nascent Society Fast-responder units (sport utility vehicles) and motor- of Emergency Medicine holds biannual dinner meetings. cycles are utilized in heavily congested and high-demand Currently, no EM journal is published in the Emirates. areas to reduce response times. Currently four motorcycles are deployed in the two most congested areas of Dubai and are available 16 h daily, except during inclement weather Organization of health-care services and during the hottest months of the year. Fast-responder units typically respond together, which can limit capacity. Dubai is almost entirely urban, and health care is delivered These units do not typically transport patients, although this though government and private hospitals, clinics and private does happen during times of system overload (COAS medical practices. In 2006, Dubai had 24 hospitals with a administration, personal communication). total inpatient capacity of more than 2,600 inpatient beds and Receiving hospitals for COAS ambulances are pri- 200 intensive care beds [12]. Approximately two-thirds of marily Rashid and Dubai Hospitals. Rashid is the the inpatient beds were at government-funded facilities, designated receiving facility for all trauma patients. under the DOHMS or MOH. Of the nearly 600 outpatient Dubai Hospital is the receiving facility for all medical clinics, over 90% are private [12]. All venues are staffed by patients except for suspected neurologic, cardiac and physicians and registered nurses; mid-level providers are not gastrointestinal patients, who are transported to Rashid recognized by the DOHMS or MOH [9]. The government or specialty hospitals. Transport decisions are made in operates a collaboration of outpatient clinics that take care of the field using triage protocols, if necessary in consul- the primary health care needs of UAE nationals and guest tation with medical control. workers. All except for the most trivial trauma are referred to Educational and licensing requirements for prehospital the Rashid Hospital Trauma Center [9]. personnel are issued by the DOHMS. These standards Health care is provided free to all citizens of the UAE. address equivalency requirements from seven other Companies that sponsor guest workers are required to countries. Continuing education is not required and provide catastrophic insurance for them. Dubai is in the typically does not occur. process of converting to a national insurance plan that One major system difference between Dubai and would allow individuals to seek acute care in the hospital of Western countries is the absence of a Good Samaritan their choice. Expatriate workers are repatriated to their Law. Although such legislation is in the works, the current home countries for long-term care. lack of protection reduces first-responder intervention. Poor 138 Int J Emerg Med (2009) 2:135–139 penetration of basic life support skills among the general of emergency surgery are taken immediately to the operating public also significantly limits this component of the EMS room after stabilization in the ED. system. Another limitation is the lack of education among Welcare Hospital, one of the larger private facilities, has the public regarding when to activate EMS. Patients with 210 inpatient beds and an annual ED census of approximately serious conditions such as acute myocardial infarction or 72,000 annual visits. No major trauma care is provided. stroke are often transported by private car instead of Welcare is a major provider of obstetrical services and ambulance. averages approximately 160 births/month. Welcare also has its own hospital-based EMS services, staffed by eight paramedics and its own ambulances. Emergency department organization

A growing number of hospitals and clinics serve the Dubai Challenges to emergency medicine population. The systems and equipment necessary to perform the highest level of emergency medical care, The development of EM in Dubai is advanced compared with including well-equipped and staffed EDs, intensive care other locations in the Middle East. The standard of emergency units, operating rooms, laboratories, and radiological and care has improved in concert with rapid economic growth. other diagnostic services, are widely available. The majority Medical resources, including infrastructure, highly trained of emergency care is provided at Rashid and Dubai Hospitals. physicians and nurses, and an extensive EMS system have all Only a small number of private hospitals provide emergency strengthened EM in Dubai. Dubai also has in place a major care and receive ambulance traffic [9]. Private hospitals may disaster contingency plan that encompasses DOHMS, MOH, have as few as 25 inpatient beds, and not all have EDs. Al government and private hospitals, and EMS [20]. Wasl hospital, a DOHMS facility, has a 24/7 ED specializing Although the practice of EM is advanced, the coordination in pediatric and obstetrical care [9]. and standardization of efforts among the various private, Rashid is the largest of the government hospitals in governmental and teaching hospitals is limited. Such coordi- Dubai. It is a 400-bed facility, with an annual ED census nation is likely to improve through the development of of 140,000 patients a year. The hospital provides postgraduate training programs in the near future. State-of- postgraduate training in medicine and surgery, as well the art teaching facilities, including a medical simulation as the new EM program. The ED population is integrated center, are expected to be complete within the next 3 years. In within a single receiving area; approximately 60% are addition, continuing medical education programs and a board surgical and 40% have medical complaints. The average certification process in EM have been initiated, and linkages age of the patients reflects the population demographics. with foreign universities with strong EM programs have been Acute traumatic emergencies are common due to the established. high incidence of industrial injuries, especially to the It the future, the development of a regional or national head and hands. Motor vehicle-related trauma is also program for accreditation in EM will be important. A common; contributing factors include poor seatbelt recognized professional organization dedicated to EM will compliance and lack of car seat use for children. serve to strengthen the specialty and coordinated and Approximately 50 patients per day are transferred by standardized emergency care throughout Dubai, and even- ambulance to the ED at Rashid Hospital. The remainder tually throughout the UAE. arrive by car, taxi, bus or on foot (Rashid Hospital ED Another major challenge for EM in Dubai is rapid staff, personal communication). expansion of the population, which is expected to double to The ED at Rashid is staffed by seven physicians at a time 3.4 million by 2015 [10]. This challenge is being addressed during peak hours. Physicians typically work in 8- or through the construction of the DHCC and other private 12-h shifts. Many of these physicians have years of hospitals. When completed, these facilities will provide more postgraduate training and function independently. Attending than 3,400 additional inpatient beds and will shift the majority physicians with recognized credentials in EM from the US, of inpatient beds from the public to the private sector [12]. Canada and the UK supervise during the daytime and are The organization of EM training and practice also available to consult on difficult cases. One attending physician presents challenges. Physicians with ED experience staff serves as the Department Head and has administrative most EDs. However, board certified or board eligible (BC/ responsibility for the ED. If a patient is critically ill, specialists BE) emergency physicians are lacking. This results in ED from general surgery, trauma surgery, orthopedics, urology, supervision by BC/BE emergency physicians occurring oromaxillofacial surgery, otolaryngology and neurosurgery only during the busiest parts of the day; at other times, BC/ can be summoned to the ED 24/7. A dedicated ED BE coverage is through telephone consultation. Fellowship anesthesiologist is available 24/7. Patients felt to be in need training in EM subspecialties is not currently planned. Int J Emerg Med (2009) 2:135–139 139

However, the completion of the academic medical center at 12. Government of Dubai. Center for Healthcare Planning and DHCC will present an opportunity to develop EM teaching Quality. Available from: http://edohms.dohms.gov.ae/mpt/ form_files/HealthCare_and_Population_Statistics.pdf. Accessed and research. Community intervention, especially in the May 7, 2009 discipline of injury control, will also be paramount. 13. Dubai Medical College for Girls. Available from: http://www. Establishing a trauma systems registry will be required to dmcg.edu/. Accessed May 7, 2009 improve the overall delivery of trauma care. 14. United Arab Emirates University. Available from: http://www. uaeu.ac.ae/colleges/. Accessed May 7, 2009 As Dubai continues to expand economically, provision of 15. World Health Organization. Available from: http://www.who.int/hrh/ emergency medical care will likely begin to match more closely wdms/media/en/United_Arab_Emirates.pdf. Accessed May 7, 2009 emergency care as practiced in Western countries. Dubai may 16. University of Sharjah. Available from: https://www.sharjah.ac.ae/ soon have one of the most advanced systems of emergency care English/Academics/Pages/DegreesandPrograms.aspx Accessed May 7, 2009 in the Middle East, which will be a model for other emirates in 17. Government of Dubai. Department of Health and Medical the UAE and other regional countries to follow. Services. Available from: http://www.dohms.gov.ae/NR/rdonlyres/ 1C56A7BD-09CB-4847-9A8F-E10A8C4012C9/706/OVERVIE WOFTHEDUBAIRESIDENCYTRAININGPROGRAMME1.pdf. Conflicts of interest None. Accessed May 7, 2009 18. Gupta K. Dubai Ambulance: working to save our lives. Gulf News. Available at: http://www.xpress4me.com/news/uae/ References dubai/20008984.html. Accessed May 7, 2009 19. Government of Dubai. Center of Ambulance Services. Available at: http://www.ambulance.gov.ae/index.php?option=com_content& 1. Dubai Chamber of Commerce. Dubai Macroeconomic Report: task=view&id=2&Itemid=9&lang=english. Accessed May 7, 2009 Multi-Sectoral Approach. Available from: http://web2.dubaichamber. 20. Muslim N (2009) Dubai working on disaster management plan for ae/pdf/reports/Dubai-Macroeconomic-Report.pdf. Accessed May 7, ports. Gulf News. Available at: http://www.gulfnews.com/Nation/ 2009 General/10204312.html. Accessed May 7 2. Bowman D. Arabian Business.com. Available from: http://www. arabianbusiness.com/518541-dubai-tourist-numbers-set-to-hit- 10mn?ln=en Accessed May 7, 2009 3. CIA—The World Factbook. United Arab Emirates. Available Robert Partridge, MD, MPH practices emergency medicine in both from: https://www.cia.gov/library/publications/the-world-fact- the clincial and academic setting, and is an Associate Professor at the book/geos/ae.html. Accessed May 7, 2009 Warren Alpert School of Medicine at Brown University. He is a 4. Blesch G (2007) Rising in the Persian Gulf. Dubai and other specialist in international health and has 20 years of experience working United Arab Emirates states are using US know-how to build a and teaching in emergency medicine throughout the world. He has cutting edge healthcare infrastructure. Mod Healthc 37(31):26–28 participated in several international disaster relief operations. Dr. 5. Government of Dubai. Dubai Statistics Center. Available from: http:// Partridge received his Bachelor of Science and Medical Degree from dsc.gov.ae/DSC/uploads/SharedDocuments/Dubai_in_Figures_23- Tufts University and his Masters in Public Health from Harvard 04-09.pdf. Accessed May 7, 2009 University. His interests are in international emergency medicine, injury 6. Globalization, Urbanization, Migration. MPI Data Hub. Available and disease prevention, and geriatrics. Dr. Partridge serves as a Board from: http://www.migrationinformation.org/dataHub/GCMM/ Examiner for the American Board of Emergency Medicine and as the Dubaidatasheet.pdf. Accessed May 7, 2009 American College of Emergency Physicians ambassador to Cuba. 7. Government of Dubai. Dubai Statistics Center. Available from: http://www.dsc.gov.ae/DSC/uploads/SharedDocuments/Gender_ Michael Abbo, MD, MEd is an American board certified residency statistics_2007.pdf. Accessed May 7, 2009 trained emergency medicine physician currently working as a 8. Government of Dubai. Dubai Statistics Center. Population and consultant at Rashid Hospital Trauma Center in Dubai, UAE. He also Vital Statistics. Available From: http://www.dsc.gov.ae/DSC/ serves as emergency medicine residency director at the same webreports/590755332OSI01-13.pdf. Accessed May 7, 2009 institution. He has a major interest in medical education and has 9. Government of Dubai. Department of Health and Medical organized and participated in several major emergency medicine and Services. Available from: http://www.dohms.gov.ae. Accessed disaster conferences in the middle east. May 7, 2009 10. Government of Dubai. Department of Health and Medical Services. Available from: http://www.dohms.gov.ae/News- Alamjit Virk, MD, MPH is an emergency physician based in Boston, Events/Events/Specialties.htm. Accessed May 7, 2009 MA. His primary interests are in emergency medicine administration 11. Dubai Health Care City. Available from: http://www.dhcc.ae and public health. He has served as a consultant advisor on a variety Accessed May 7, 2009 of projects in international health.